Using the Community Action Model to Combat Tobacco (2001)

The San Francisco Tobacco-Free Project has funded a number of Community Capacity Building (CCB) projects in the Latino, African American, and Asian Pacific Islander communities to implement strategies for environmental change including policy development and media advocacy. CCB is also known as the CAM or Community Action Model. CCB uses popular education theory to assist youth/adult advocates in affecting environmental change at local and global levels.

The CCB process has resulted in a ban on tobacco promotional items in San Francisco schools, a “bidi” project resulting in a complaint filed with the Federal Trade Commission and a policy to ban outdoor smoking at public recreation and playground facilities in San Francisco. Finally, a number of CCB projects collaborated in an effort resulting in the adoption by the San Francisco Board of Supervisors of a resolution to the U.S. Congress that U.S. based Transnational Tobacco Companies (TNT’s) adhere to the same standards internationally as domestically. Lessons learned include that the funding source must define and provide criteria for an “action” or outcome and provide concrete examples, and must provide ongoing technical assistance and training throughout the CCB process especially with respect to the diagnosis step.

Traditional health education efforts have focused on interventions that attempt to change the lifestyle of the individual through education. The environmental approach assumes that individuals become tobacco users primarily due to the efforts of the tobacco transnationals and other environmental factors such as accessibility of tobacco and promotion through the media which can be changed by addressing social norms, rules and regulations of institutions and governments.

The intent of CCB is to work in collaboration with communities and provide a framework for community members to acquire the skills and resources to investigate the health of the community or neighborhood where they live and then plan, implement and evaluate actions that change the environment to promote health. The CCB Model is asset based. It focuses on the strengths or capacities of a community to create changes from within.

The CCB model adheres to the following principles. It is influenced by “popular education” theory and practice in Latin America and around the world which itself builds upon the work of Paulo Freire among others. There is a focus on environmental change rather than individual change since the greatest number of forces that affect the public’s health can be found in the physical and socio-cultural environment (economics, education, employment, etc.). The model builds on strengths, resources, and assets of a community (as opposed to needs assessments) and builds the capacity of the community to address the health issues of concern to them. This model was perceived to be appropriate for tobacco control in San Francisco because it promotes efforts that are community driven and community owned.

Tobacco control efforts in San Francisco address three areas: stopping the promotion of tobacco; stopping illegal access for minors, and protecting residents from exposure to second hand smoke. San Francisco is an ethnically diverse city and its tobacco control efforts have included the development of a policy framework to counter the global impact of tobacco transnationals through local actions.

This paper will begin with a description of the Community Capacity Building model which will be followed by four examples of how the model was implemented in San Francisco.

CCB projects are funded for a one to two year period. During that time they follow these four steps in the CCB process: 1) Recruit and train community advocates many of whom are youth. Interactive trainings are designed by the health educators of the Tobacco-Free Project (TFP) of the San Francisco Health Department and provide skill building practice to complete each of the steps. Trainings facilitate the sharing of existing skills and community strengths so that actions are community driven. Advocates collectively identify issues of concern in their community including how the tobacco industry targets their community;

2) Diagnosis/Action Research: Advocates collect information via community opinion surveys, interviews of key leaders, potential policies research, existing records assessments, and neighborhood & community mapping (community members identify the physical boundaries of their neighborhood/community and then map out the institutions, businesses, agencies, organizations, strengths, skills and knowledge of community members); 3) Analyze the Diagnosis Findings: Advocates acquire the skills to analyze the information they gathered and list recommendations for change; 4) Choose and Implement an Action: The Action should be: 1)achievable, 2) have the potential for sustainability, and 3) compel a group/agency/organization to change the community or neighborhood where they live for the well being of all. Actions are defined and examples provided in trainings. Community members create and implement an action plan which may include an outreach plan, media advocacy plan, developing a model policy, advocating for a policy, and making presentations. An evaluation component is included in each plan.

A total of nine CCB projects were funded over a 16 month period between 1996-1998. Many of these projects targeted specific communities of color in San Francisco. Three of the projects are described below. Finally, a description of a CCB effort to address something about the global impact of the transnational tobacco companies locally that involved a collaboration of seven of the CCB projects is provided.

Example 1: Chinese Progressive Association; Ban on Tobacco Promotional Items in SF Schools. Project staff recruited and trained a core group of 6-8 advocates. In addition a number of advocates participated in certain activities such as conducting surveys, but did not participate during the entire process. During the diagnosis phase, the project identified Chinatown as its community, mapped the community, and identified community strengths and assets. The advocates identified the tobacco industry as the root problem of teen smoking. Over a period of two months, advocates conducted eight surveys (community opinion survey, merchant survey, key leader interview, purchase survey, advertising survey, smoker survey, tobacco access survey, survey of existing laws). Advocates then went on a day and a half retreat to analyze the information they had gathered. Based on the analysis of the information they had gathered, the advocates identified potential actions and decided to advocate for a school wide policy to ban the wearing and carrying of tobacco promotional items in the public schools. They developed their action plan and implemented it. This included a petition to support the policy and the gathering of over 1,000 signatures of students, parents and concerned community members. They sought the support of a School Board Member who introduced a resolution to the full School Board. The Advocates sent out information to potential allies (community organizations, schools and individuals), and made presentations to other groups regarding the proposed policy. With the assistance of the Tobacco-Free Project media contractor, the advocates conducted an active media campaign to publicize the results of the survey to advocate for the passage of the proposed policy. They mobilized 35 students, parents, and concerned community members to attend the May 28, 1996 School Board meeting to support the proposed policy and present the results of their work. The School Board passed the proposed policy and it was included in the Parent/Student Handbook for the 1996-1997 school year. At each step of this process, the Tobacco-Free Project health educator provided training and technical assistance and met with the project staff on an ongoing basis. This included assistance in planning retreats, drafting model policies, strategizing for meetings with the school board, strategic action planning and timeline planning ideas, and problem solving with last minute unexpected difficulties.

Example #2: Booker T. Washington Community Service Center (BTW) files a complaint regarding Bidis to the Federal Trade Commission. Booker T. Washington Community Service Center is located in a largely African American neighborhood in San Francisco. BTW youth advocates raised a concern about the use of a tobacco product called “bidis” among African American youth in their neighborhood. Tobacco-Free Project health educators assisted them in designing their diagnosis. They a) researched bidis and found they were Indian cigarettes that had seven times as much nicotine as regular cigarettes; b) designed a survey which was completed by over 600 youth in San Francisco schools and found that over 2/3rds knew someone who smoked bidis; and c) designed a purchase survey and were able to buy bidis 24% of the time (compared to a 16% success rate for regular cigarettes) and found that 70% of beadies purchased had no warning label. They received assistance from the San Francisco Tobacco-Free Project health educators in preparing for a meeting with the Federal Trade Commission about their findings at which they filed a complaint with the Federal Trade Commission about warning labels and related issues. They also received assistance from Tobacco-Free Project health educators in preparing for a press conference covered by CNN, local papers and local radio and TV news stations. As a result of the Booker T. Washington youth advocates’ efforts, compliance checks of local laws regarding sales to minors will now include bidis. Finally, advocates became aware that bidis involve child labor issues in India and are pursuing solidarity work in that arena. Again, Tobacco-Free Project assisted BTW staff and youth advocates in planning and strategizing at all stages of the process including designing the three components of the diagnosis, data analysis, preparing the youth advocates to present their project findings and problem solving.

Example #3: South Of Market Center (SOMA): Tobacco-Free Advocates Create Smokefree Playgrounds. The South of Market Center is located in an area with a large Pilipino population in San Francisco. The youth advocates’ decision to approach the Recreation and Parks Commission was based on their finding that youth in the South of Market area have very few recreational facilities available to them in the low-income South of Market neighborhood. Additionally, the South Of Market Recreation Center was full of smokers including youth. The youth felt they needed a safe place outdoors that was free from smoke as a way to create changes in social norms regarding tobacco use. They approached the Recreation and Park Acting General Manager, they obtained his support for adopting a smokefree policy at South Of Market Recreation Center, as well as in other facilities with defined recreation and play areas for children. At a public hearing on June 18, 1998, the Recreation and Park Commission adopted a smoke free policy that was consistent with their mission to provide “safe and well maintained facilities and parks and opportunities for safe recreation and positive social and personal development”.

Example #4: Same Standards for U.S. Based Tobacco Transnationals: Youth from seven CCB projects participated in trainings on the global impact of transnational tobacco companies (TNT’s). They learned about their impact on the environment, child labor, pesticides, economics and politics. They learned how the marketing and lobbying practices of TNT’s use the same strategies to target people abroad as they do in the U.S. They collaborated on drafting a resolution to the SF Board of Supervisors calling for U.S. companies to adhere to the same standards internationally as nationally. They also produced a booklet of poetry, quotes, and documentation entitled, “What’s Real About the Global Impact of Tobacco by SF Youth”. The resolution was adopted and sent to Federal policy makers at a time when such standards were being discussed as part of national policy.

Tobacco-Free Project staff facilitated this process by training youth advocates on the global impact of tobacco, initially facilitating ongoing meetings of the youth advocates from the seven groups, working with a core group of three youth who collected booklet contributions and then designed the booklet itself, and supporting project staff and youth advocates as they became familiar with the process of approaching a city policy maker to adopt a resolution.

In all cases, Tobacco-Free Project staff learned that ongoing technical assistance and training was key. Since the goal of the CCB process was that it be community driven and based on action research, the outcome of each project was uncertain at the beginning of the project term. Tobacco-Free Project staff and evaluation contractor staff provided assistance to design the diagnosis tools, help advocates collect and analyze the data, assist advocates in designing their action plans that include making policy, and identifying decision-making bodies who were user friendly so that youth and adult advocates could access them. In addition, Tobacco-Free Project staff helped conduct media advocacy, and gain access to resources to provide media and evaluation support.

Tobacco-Free Project staff learned that providing resources so that a core of advocates could be maintained throughout the process was also essential. Ongoing staff and advocate turnover at community agencies is always an ongoing challenge to implementing the CCB process.

Finally, trainings that clearly defined the CCB steps, that outlined examples of how to diagnose an issue and that gave a concrete definition of an “action” with examples was necessary. Early groups interpreted an action as an educational intervention (health fair or painting a “no-smoking” mural). As a result, Tobacco-Free Project health education staff realized that providing concrete policy-development and community organizing skills in trainings went hand-in-hand with requiring that projects develop and implement an action as part of their workplan.

Youth Advocates developed their action plan and implemented it. This included a petition to support the policy and the gathering of over 1,000 signatures of students, parents and concerned community members. They sought the support of a School Board Member who introduced a resolution to the full School Board. The Advocates sent out information to potential allies (community organizations, schools and individuals), and made presentations to other groups regarding the proposed policy. With the assistance of the Tobacco-Free Project media contractor, the advocates conducted an active media campaign to publicize the results of the survey to advocate for the passage of the proposed policy.

Advocates mobilized 35 students, parents, and concerned community members to attend the May 28, 1996 School Board meeting to support the proposed policy and present the results of their work. The School Board passed the proposed policy and it was included in the Parent/Student Handbook for the 1996-1997 school year.

At each step of this process, the Tobacco-Free Project health educator provided training and technical assistance and met with the project staff on an ongoing basis. This included assistance in planning retreats, drafting model policies, strategizing for meetings with the school board, strategic action planning and timeline planning ideas, and problem solving with last minute unexpected difficulties.

Booker T. Washington Community Service Center is located in a largely African American neighborhood in San Francisco. Project staff recruited a core group of 8 to 10 youth advocates. Initially, there was a lot of turnover of advocates which was addressed by staff developing an incentive system, writing up rights and responsabilities of advocates, weekly meetings and interesting field trip events. BTW youth advocates raised a concern about the use of a tobacco product called “beadies” among African American youth in their neighborhood.

Tobacco-Free Project health educators assisted BTW advocates in designing their diagnosis. Since very little was known about beadies, the advocates decided to do a three pronged diagnosis: researching beadies at the library and on the internet, surveying their peers (other youth) about beadie use and information, and doing a beadie purchase survey at local stores. At each step they defined the questions to be asked and designed the tool to be used.

The advocates analyzed their diagnosis and found the following:

beadies were Indian cigarettes that had seven times as much nicotine as regular cigarettes;

a survey which was completed by over 600 youth in San Francisco schools found that over 2/3rds knew someone who smoked beadies;

a purchase survey showed youth were able to buy beadies 24% of the time (compared to a 16% success rate for regular cigarettes) and found that 70% of beadies purchased had no warning label.

The advocates came up with a list of recommendations and decided to look into enforcement of laws regulating warning labels and sales of beadies to minors. They also decided do education and media work about beadies and to find out more about beadies as a child labor issue in India.

The BTW advocates chose to file a complaint with the FTC regarding the lack of warning lables on Beadies. Youth advocates received assistance from the San Francisco Tobacco-Free Project health educators in: preparing for a meeting with the Federal Trade Commission at which they filed a complaint about warning labels and related issues preparing for a press conference covered by CNN, local papers and local radio and TV news stations including beadies in compliance checks of local laws regarding sales to minors.

Finally, advocates became aware that beadies involve child labor issues in India and are pursuing solidarity work in that arena. Again, Tobacco-Free Project assisted BTW staff and youth advocates in planning and strategizing at all stages of the process including designing the three components of the diagnosis, data analysis, preparing the youth advocates to present their project findings and problem solving.